Range of Motion to Impingement Curves Create a New Patient-Specific Impingement-Free Zone for Acetabular Cup Placement

Abstract

Introduction: The acetabular “safe zone” has recently been questioned as a reliable reference for predicting total hip arthroplasty impingement and instability as many dislocations occur within the described parameters. Recently, an improved understanding of spino-pelvic mechanics has provided surgeons useful information to both identify those at a higher risk of dislocation and, in some cases, allows altering component positioning to accommodate the patient’s individual “functional” range of motion. The purpose of this study was to create a new patient-specific impingement-free zone by considering range of motion (ROM) to prosthetic impingement for both high flexion and extension poses, thus demarcating a zone that avoids both anterior and posterior impingement, thereby creating an objective approach to identifying a patient’s ideal functional safe zone. Materials and Methods: A validated hip ROM three-dimensional simulator was utilized to create ROM-to-impingement curves for both high flexion as well as pivot and turn poses. The user imported a computerized tomography (CT) with a supine pelvic tilt (PT) value of zero and implant models (tapered wedge stem, 132° neck angle, 15° stem version, 36mm femoral head). Femur-to-pelvis relative motions were determined for three upright seated poses (femur flexed at 90° and 40° internal rotation, with 0°, 10°, and 20° posterior PT), one chair rise pose (femur flexed at 90° and 0° internal rotation, with the pelvis flexed anteriorly until the pelvis made contact with the femur), and three standing pivot and turn poses (femur set at 5° extension, and 35° external rotation, with 5° posterior PT, 0°, and 5° anterior PT). ROM-to-impingement curves for cup inclination versus anteversion were graphed and compared against the Lewinnek safe zone. Results: The ROM-to-impingement curves provide an objective assessment of potential impingement sites as they relate to femoral rotation and pelvic tilt. The area between the stand and sit curves is the impingement-free area. A sitting erect pose with a simulated stiff spine (0° PT) yielded less impingement-free combinations of cup inclination and version than poses with greater than 0° posterior pelvic tilt. Conclusion: The results demonstrate that the acetabular target zone has a relatively small margin for error between the sitting and standing ROM curves to impingement. Importantly, anterior and posterior pelvic tilt can markedly increase the risk of impingement, potentially leading to posterior or anterior dislocations, respectively. This study highlights the importance of correctly identifying the patient-specific functional range of motion to execute optimal component positioning.